Circulation

ECG CHALLENGE

A Series of Abnormal ECGs: Are They

Benign or Sinister?
Hongdan Duan, MM; Chuan-Hai Zhang , MD

ECG CHALLENGE obtained (shown in Figure 1A), after which two more con-
secutive ECGs were obtained (shown in Figure 1B and 1C).
A 36-year-old man presented to the hospital for routine What do these ECG changes represent? What is the
physical examination. He was otherwise asymptomatic. His mechanism behind them?
vital signs and laboratory results were normal. An ECG was Please turn the page to read the diagnosis.
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Figure 1. Patient’s ECGs.

A, ECG obtained on initial presentation. B and C, Repeat ECGs (continued).

 
Correspondence to: Chuan-Hai Zhang, MD, First Affiliated Hospital of Jinzhou Medical University, Renmin Street, Jinzhou, Liaoning, China 121000. Email
zch8598145@yeah.net
For Sources of Funding and Disclosures, see page 1410.
© 2023 American Heart Association, Inc.
Circulation is available at www.ahajournals.org/journal/circ

Circulation. 2023;147:1407–1410. DOI: 10.1161/CIRCULATIONAHA.123.064375 May 2, 2023 1407

 Duan and Zhang ECG Challenge
CASES AND TRACES
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Figure 1 Continued.

1408 May 2, 2023 Circulation. 2023;147:1407–1410. DOI: 10.1161/CIRCULATIONAHA.123.064375

 Duan and Zhang ECG Challenge

RESPONSE TO ECG CHALLENGE Most ECG devices record leads I and II and then derive
other limb leads from these 2 leads.3 The calculation for-

CASES AND TRACES

Three different shapes of T-waves were recorded in 3 mula for each lead is shown in Table 1. From these formu-
ECGs. These ECG changes are artifacts caused by arte- las, we can conclude that when the electrode of the left leg
rial pulsation of the left leg. When one limb electrode is is disturbed by arterial pulsation, the ECG will have several
clipped on an artery of the limb, artifacts will appear on noteworthy characteristics (Figure 1). The direction of the
ECG. Similar artifacts can also occur as a result of radial artifacts is upward in leads II, III, and aVF, and downward
arterial pulsation, especially in patients with forearm ar- in aVR, aVL, and all precordial leads. Artifacts of maxi-
teriovenous fistula.1 When the electrode clamped to the mum amplitude appear in leads II, III, and aVF, whereas
patient’s left leg was moved near the heart and the ECG amplitude of the artifacts in leads aVR and aVL and in the
was recorded again, these bizarre ECG changes com- precordial leads would be one-half and one-third of the
pletely disappeared (Figure 2). amplitude in the inferior leads, respectively. Lead I would
In fact, ECG changes caused by arterial pulsation show no artifact. Therefore, only one limb lead (I, II, or III)
has a unique effect on phase, leads distribution, direc- will remain unaffected when the artifact originates from
tion, and amplitude. The arterial pulse is generated by any one limb (Table 1). This is the most important and
the contraction of the heart. Therefore, the ECG arti- simplest method for detecting the ECG artifact caused by
fact caused by arterial pulsation is synchronized with arterial pulsation originating from a single limb.
the rhythm of the heart, that is, the ratio of the artifact This case illustrates that when the artifact originates
to the QRS complex is 1:1. Since the QRS complex from a single limb’s arterial pulsation, the calculation
appears at the beginning of cardiac contraction, the formula of each lead can be used to determine the
subsequent arterial pulsation will lead to the appear- amplitude and direction of the artifact in all the leads.
ance of artifacts, so these artifacts appear after the Simultaneously, this case also shows that the arterial
QRS complex (in the repolarization phase), and have a pulsation of the same limb can cause ECG artifacts of
fixed coupling interval with QRS complex. The early or different morphologies and amplitudes (Figure 1), which
late appearance of the artifact during the repolarization may be due to the difference in contact position, area,
phase depends on how far the culprit electrode is from and angle between the culprit electrode and the artery
the heart.2 during ECG recording. To the best of our knowledge,
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Figure 2. ECG obtained after moving the electrode near the heart.

Circulation. 2023;147:1407–1410. DOI: 10.1161/CIRCULATIONAHA.123.064375 May 2, 2023 1409

 Duan and Zhang ECG Challenge

Table 1.  Calculation Formula and Direction of Artifact for Each Lead
CASES AND TRACES

Lead I II III aVR aVL aVF VN

Calculation formula E L-E R E F-E R E F-E L E R-½(E L+E F) E L-½(E R+E F) E F-½(E R+E L) EVN-⅓(E R+E L+E F)
Source of artifact
 Left leg No artifact* Upward Upward Downward Downward Upward Downward
 Left arm Upward No artifact* Downward Downward Upward Downward Downward
 Right arm Downward Downward No artifact* Upward Downward Downward Downward

The formulas presented in the table consider the electrode negative (indicated by -) when the current is moving away from it. When arterial pulsation affects the
potential of the positive electrode in a certain lead, the artifact has upward deflection; when the arterial pulsation affects the potential of the negative electrode in a
certain lead, an artifact with a downward deflection appears. In our case, the artifact originated from the left leg and did not affect the potential of lead I, so lead I shows
no artifact. In leads II, III, and aVF, arterial pulsation affects the potential of the positive electrode, so the direction of the artifact is upward. In leads aVR and aVL, as
well as all precordial leads, arterial pulsation affects the potential of the negative electrode, so the direction of the artifact is downward. Similarly, the direction of the
artifact in each lead can be inferred when arterial pulsation comes from the left or right hand, as supported by the calculation formulas presented in the Table. Accord-
ing to these formulas, we can also calculate the change in artifact amplitude of each lead, which is caused by the direction of the current toward or away from the
electrode. The amplitude of the artifact is indicated as 1 (ie, maximum amplitude), one-half, or one-third. In our case, the artifact originated from the left leg; therefore,
lead I showed no artifact. Artifacts of maximum amplitude (ie, 1) appeared in leads II, III, and aVF, whereas artifact amplitude in leads aVR and aVL, and in the precordial
leads were one-half and one-third of the amplitude in the inferior leads, respectively. E F indicates the potential at the left leg connection; E L, the potential at the left arm
connection; E R, the potential at the right arm connection; EVN, the potential at any precordial connection; F, left leg; L, left arm; R, right arm; and VN, any precordial lead.
*One limb lead remains unaffected when artifact originates from either of the other limbs.

this is the first report on ECG artifacts of different mor- Disclosures

phologies caused by the pulsation of the same artery. None.

ARTICLE INFORMATION REFERENCES

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Sources of Funding
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1410 May 2, 2023 Circulation. 2023;147:1407–1410. DOI: 10.1161/CIRCULATIONAHA.123.064375